Tuition: The cost for the program is $ , which must be paid in full before course begins.

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1 Ossining Extension Center Integrated Patient Care Technician Program Application Process 2014 The integrated patient care technician program (IPCT) is a 120-hour program designed to prepare Certified Nursing Assistants to serve as Patient Care Technicians (PCTs). PCTs who function as multi-skilled care providers in a variety of health-care settings. The program is designed to prepare an individual to work in hospital, long-term care, or skilled nursing facilities. The program provides the CNA the opportunity to gain additional skills to be prepared to perform routine patient care treatments including simple lab tests, EKG s, simple dressing changes, phlebotomy, current technology. The technician will receive education on standard and universal health care precautions; therapeutic communication techniques, English and math skills, customer service, and patient care delivery systems. Upon successful completion of the program, students are eligible to take the Certified Patient Care Technician exam offered by the National Health career Association (please be prepared to pay a separate fee of $149 for the exam online at NHAnow.com). Prerequisite: In order to be eligible for the Integrated Patient Care Technician program, individuals must have a valid license as a Certified Nurse Assistant in New York. Tuition: The cost for the program is $ , which must be paid in full before course begins. There are additional fees for this program that include: 1. Non-refundable application fee of $25 2. $15 malpractice insurance due in the first module payment 3. Additional Costs: Text books, fee for certification exam, CPR, background and drug checks, transportation to externship site, and any additional supplies or uniforms. Refunds For requests received at least 2 business days prior to the start of the class: 100% refund. There are no refunds after that. All refund requests must be made to the college in writing or ed to If you paid by check, please allow 6-8 weeks for your refund to be processed. Credit card refunds are processed immediately. General Schedule: The integrated patient care technology program will start on Tuesday February 11, 2014 and end on May 15, Classes are held on Tuesdays/Thursdays 4:30pm-9:30pm: Didactic/Lecture February 11- April 15, 2014 T/F-4:30pm-9:30pm Clinical Externship April 22- May 15, 2014 T/F-4:30pm-9:30pm

2 ***You must successfully complete all coursework including the externship, pass the National Certification examination for the Patient Care Technician (CPCT), and complete all financial obligations of the program to become a Certified Patient Care Technician. *** 1. Individuals interested in this credential must submit an application packet containing the following documentation by January 13, 2014: A completed Integrated Patient Care Technician application Copies of certificates of course completion for: the Certified Nursing Assistant Program A valid New York State Certified Nurse assistant registration (other states CNA certifications may be submitted for consideration, but are not guaranteed acceptable for this requirement) $25 application for admission non-refundable fee. Please make out check or money order to Westchester Community College The completed packet must be submitted to: The Ossining Extension Center, Westchester Community College 22 Rockledge Avenue, Ossining, NY Attn: C. Jones 2. Complete the top half of the recommendation form and submit to each reference person. Please make sure they understand you need the document submitted in a timely fashion so that it is here by January 13, Please provide a stamped envelope that is addressed with the address listed above so they can return it easily. 3. Once your application is received, you will be screened. You will be scheduled for an interview and reading exam if appropriate. All candidates must successfully complete the screening interview prior to acceptance to the program. Additional Requirements Before the externship starts, students are responsible for: You must complete a background check and the drug test from CertifiedBackground.com prior to the start of the program. Providing a copy of current CPR certification Submitting the Integrated Patient Care Technician Physical Examination Record form. Obtain a physical examination from a licensed physician and submit the physical examination record before the externship starts. Submitting any additional tests, forms, or clearance procedures as required by the externship site. Acquiring the appropriate shoes and or uniform as stipulated by the externship site. Fulfilling all attendance and financial requirements of the program. Westchester Community College adheres to the policy that no person on the basis of race, color, creed, national origin, age, gender, sexual orientation, or handicap is excluded from, or is subject to, discrimination in any program or activity.

3 Integrated Patient Care Technology Program Westchester Community College-Ossining Extension Center Application for Admission Spring 2014 Please complete all of the following, and print or type clearly. Today s Date: Social Security Number Date of Birth Sex: Male or Female Last Name First Name Middle Initial Legal Street Address City State Zip Code Home Phone Number (Area Code + Number) Business or Cell Phone Number (Area Code + Number) $ Application Fee Enclosed $25 Are you a U. S. Citizen? YES NO Do you have a permanent resident card? YES NO Authorization to work or stamped passport? YES NO Do you have a high school diploma/ged YES NO If yes, date issued: List college(s) or institution(s) attended and degree earned: Degree/Credits:

4 Integrated Patient Care Technology Program Recommendation Form TO THE APPLICANT: Fill in all information in this section and forward this form to the recommender. The recommender must return the completed form to Westchester Community College, Ossining Extension Center, 22 Rockledge Ave, Ossining, NY 10562, Attention: IPCT Program. For the convenience of the recommender, you should include an addressed, stamped envelope. The reference must be from someone who is familiar with your professional work and/or career goals. References are not acceptable from relatives, in-laws, or friends. Please print: Name: Last First M.I Applicant s Signature Date: TO THE RECOMMENDER: Thank you for providing information regarding the individual above; she/he is applying for enrollment in the Integrated Patient Care Technology Program at Westchester Community College-Ossining Extension Center. Name of Recommender: (Please Print): Last Name: First Name: Organization: Address: (Area Code) Phone # Relationship to the applicant Signature: Please see reverse side

5 Name of the applicant: Please evaluate the applicant by checking the appropriate spaces below: Qualifications Excellent Good Average Below Average 1. Ability to work with adults & children as clients in a health care setting 2. Perseverance 3. Verbal communication skills 4. Written communication skills 5. Punctuality 6. Ability to work with others as a team (co-workers) Please feel free to add any additional comments: Signature Date: Please return the completed form to: Westchester Community College, Ossining Extension Center, 22 Rockledge Ave, Ossining, NY 10562, Attention: IPCT Program Or Fax to:

6 Integrated Patient Care Technology Program Recommendation Form TO THE APPLICANT: Fill in all information in this section and forward this form to the recommender. The recommender must return the completed form to Westchester Community College, Ossining Extension Center, 22 Rockledge Ave, Ossining, NY 10562, Attention: IPCT Program. For the convenience of the recommender, you should include an addressed, stamped envelope. The reference must be from someone who is familiar with your professional work and/or career goals. References are not acceptable from relatives, in-laws, or friends. Please print: Name: Last First M.I Applicant s Signature Date: TO THE RECOMMENDER: Thank you for providing information regarding the individual above; she/he is applying for enrollment in the Integrated Patient Care Technology Program at Westchester Community College-Ossining Extension Center. Name of Recommender: (Please Print): Last Name: First Name: Organization: Address: (Area Code) Phone # Relationship to the applicant Signature: Please see reverse side

7 Name of the applicant: Please evaluate the applicant by checking the appropriate spaces below: Qualifications Excellent Good Average Below Average 7. Ability to work with adults & children as clients in a health care setting 8. Perseverance 9. Verbal communication skills 10. Written communication skills 11. Punctuality 12. Ability to work with others as a team (co-workers) Please feel free to add any additional comments: Signature Date: Please return the completed form to: Westchester Community College, Ossining Extension Center, 22 Rockledge Ave, Ossining, NY 10562, Attention: IPCT Program Or Fax to:

8 Integrated Patient Care Technician Program Ossining Extension Center Physical Examination Record 2014 Applicant: Please complete the information requested below (including your signature, and then give the form to your medical provider so that your health status can be documented. Thank you. Print Name Social Security Number Date of Birth New York State Health Code 405, requires that this ANNUAL Physical Examination Report form be fully completed and on file Ossining Extension Center BEFORE the start of the program. Failure to comply will result in suspension without refund from clinical classes. The affiliating agency may ask to see copies of this report. According to New York State Law, you may be tested for drugs and alcohol abuse. The use of drugs and alcohol can jeopardize your student status in the medical curricula. Please ALL LABORATORY sign your name AND indicating TITER that REPORTS you understand MUST ACCOMPANY the directions and THIS conditions RECORD of this form. Hepatitis B Core Antibody Results: OR Hepatitis Vaccine Series: 1) 2) 3) Blood Titer* Measles Mumps Rubella Varicella Required Titer: Numerical Value Immune Non-Immune Immunization ** * Returning Students ONLY: if original titers showed immunity; there is no need to repeat them ** Immunization is required if titers show non-immunity Annual PPD Test: Tuberculosis Screening Date Result If PPD is positive; a chest x-ray is required. Please enclose report. Chest x-ray results: Date Result Tetanus Vaccine: Vaccine Date Tetanus Vaccine must have been administered within the past 10 years Date/Signature of Medical Provider PLEASE COMPLETE THE REVERSE SIDE

9 Print Last Name First Middle Age: Height: Sex: Weight: Blood Pressure: Physical Examination-Description, Comments, and/or Recommendations Vision Hearing Nose Throat Teeth Thyroid Heart Abdomen Kidneys Extremities Reflexes Current Medications: Lungs Comments: Breasts Is this student physically and emotionally able to participate in the curriculum of his/her choice, which involves classroom and laboratory activities and clinical practice? If not, please specify: Pursuant to: State of New York Department of Health memorandum, series 88-66, 3/22/88 Health Facilities Series: H-40 Subject: Revised Part 405 Hospitals - Minimum Standards This examination is of sufficient scope to ensure that the examined student of this date, is able to assume his/her duties free from a health impairment, which is of potential risk to the student The patient served by the student or which might interfere with the performance of his/her duties, including the habituation or addiction to depressants, stimulates, narcotics, alcohol or other drugs or substances, which may alter the individuals behavior. EXAMINING HEALTH CARE PROVIDER DATE: ADDRESS: Signature Please Print Name TELEPHONE: The contents of this report are confidential; information will be released only by court order or written consent of individual identified on this form

10 WESTCHESTER COMMUNITY COLLEGE Ossining Extension Center Integrated Patient Care Technology Program HEPATITIS B VIRUS INFORMATION SHEET The U.S. Occupational Safety and Health Administrator (OSHA) issued a new Blood borne Pathogens Standard in December The rule applies to all employers who have workers that may come in contact with blood or other body fluids during the performance of their job, putting them at risk of contracting highly contagious viral infections. Health Science student, because of the nature of their occupational training, may also be at risk of contracting these same blood borne infections. Blood borne pathogens include the Hepatitis B Virus (HBV) and Human Immunodeficiency Virus (HIV) which causes AIDS. HBV is a potentially life-threatening virus. The CDC (Centers for Disease Control) estimates there to be approximately 280,000 HBV infections each YEAR IN THE United States, about 8,700 of these includes health care workers. The observation of Universal Precaution technique and the utilization of protective clothing and equipment may prevent exposure to potentially infectious materials. However, the best defense against Hepatitis B Virus is vaccination. Although it is not a medical requirement, it is strongly recommended that you consider being vaccinated. If anytime you are exposed to a blood borne pathogen, a report of the incident MUST be filed with the clinical affiliate, curriculum chairperson and the student Health Services Office. PLEASE COMPLETE: I understand that due to occupational exposure to blood or other potentially infectious materials, I may be at risk of contacting the HBV infection. I have been informed of the importance and benefits of the HBV vaccination and it has been strongly recommended that I be vaccinated. Please indicate your status/decision regarding hepatitis B vaccination: 1. Begun/Completed Vaccination Series: Vaccination Dates: 1) 2) 3) 2. My signature indicates that I have decided not to be vaccinated at this time. Signature Date

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